Centralized rehabilitation after severe traumatic brain injury--a population-based study.

OBJECTIVES: To present results from the first 3 years of centralized subacute rehabilitation after very severe traumatic brain injury (TBI), and to compare results of centralized versus decentralized rehabilitation. MATERIAL AND METHODS: Prospectively, the most severely injured group of adults from an uptake area of 2.4 million in Denmark were included at admission to a regional brain injury unit (BIU), on average 19 days after injury. Patients in the retrospective study used for comparison were randomly chosen from the national hospital register. RESULTS AND CONCLUSIONS: Out of 117 patients in the prospective study, six died, and 92 (1.27 per 100,000 population per year) survived after a post-traumatic amnesia (PTA) period of at least 28 days. All 19 patients with PTA 7-27 days and 48% of survivors with PTA at least 4 weeks were discharged directly home. The incidence of patients vegetative at 1 month post-trauma was 0.29, and at 1 year 0.055 per 100,000 population. By comparison of 39 patients from the centralized unit injured in 2000-2003 with 21 patients injured in 1982, 1987 or 1992 and with similar PTA- and age distributions and male/female ratio, Glasgow Outcome Scale score at discharge was significantly better for the former group.

Conservative bladder management in advanced multiple sclerosis.

Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.

Sympathetic vasoconstrictor responses in multiple sclerosis with thermo-regulatory dysfunction.

Centrally and locally mediated sympathetic vasoconstrictor responses in skeletal muscle and subcutaneous tissue were studied in six patients with definite multiple sclerosis and severely affected thermoregulatory sweating. The purpose of the study was to evaluate vasomotor function in patients with pronounced thermoregulatory dysfunction and to differentiate between locally and centrally elicited vasomotor reflexes in two different tissues. The method used, the 133-Xenon washout technique, makes such a distinction possible. In spite of the severe sweating disturbances, we found centrally and locally mediated sympathetic vasomotor reflexes to be preserved in skeletal muscle and subcutaneous tissue. The results support the view that sudomotor and vasomotor functions are independently controlled. Previously described differences in sympathetic vasoconstrictor responses in skeletal muscle and subcutaneous tissue in several other neurological disorders are not present in patients with multiple sclerosis, based on our results.

Disturbances of ano-rectal function in multiple sclerosis.

Thirty patients with multiple sclerosis (MS) [18 men and 12 women, mean age 40 years (range 22-50), disease duration 12 years (range 0.5-34), Kurtzke's Expanded Disability Status Score 6.0 (range 4.0-7.5)] were interviewed about bowel symptoms and studied using ano-rectal manometry. The results were compared with findings in healthy controls. Twenty-eight had bowel symptoms: 8 constipation, 10 constipation and infrequent faecal urgency, 4 infrequent faecal incontinence and 6 frequent faecal incontinence. Anal sphincter pressure at rest was significantly reduced in MS patients 69 (SD 17) cm H2O, compared with 92 (SD 15) cm H2O in controls, and the external sphincter contraction force was also significantly reduced. Rectal sensation and rectal compliance were reduced and the ano-rectal inhibition reflex (defaecation reflex) required a higher rectal pressure to be elicited in the patients. Upon rectal filling, an early external sphincter excitation was seen. The presence of faecal incontinence correlated strongly with reduced rectal sensation. The findings suggest that faecal incontinence can at least partly be explained by low anal sphincter pressure and poor rectal sensation. The findings of early sphincter excitation and increased threshold of ano-rectal inhibition reflex may be an important pathophysiological factor for constipation in MS patients.

Plasma exchange combined with azathioprine in multiple sclerosis using serial gadolinium-enhanced MRI to monitor disease activity: a randomized single-masked cross-over pilot study.

We enrolled 11 patients with secondary progressive MS in a randomized single-masked cross-over study of plasma exchange (PE) in combination with azathioprine 2 mg/kg. PE was performed once a week for 4 weeks and thereafter every second week for 20 weeks (14 treatments). Eight patients completed the whole trial, and three patients discontinued the trial, two during the run-in period of azathioprine treatment and one at the introduction of PE. The primary efficacy variables were the number of gadolinium-enhancing lesions and the occurrence of new enhancing lesions on serial MRI performed every 3 weeks during the PE and the control period. Secondary efficacy variables were the total MS lesion load on T2-weighted MRI, multimodal evoked potentials, and clinical neurologic ratings. No significant differences were found regarding the number of enhancing lesions or occurrence of new enhancing lesions in the two periods. Although the total MS lesion load on MRI was significantly lower (p < 0.02) and central motor conduction times decreased significantly (p < 0.05) during PE, this small study did not provide sufficient evidence for a significant beneficial effect of PE or encourage a subsequent large randomized parallel group study.

Biofeedback treatment of bladder dysfunction in multiple sclerosis. A randomized trial.

Fifteen women and five men with bladder dysfunction due to multiple sclerosis were randomized to plus/minus biofeedback using bladder pressure and simultaneous EMG registration via surface electrodes. All the patients had behavioural modification, pharmacological adjustment and pelvis floor training. The number of incontinence episodes decreased and maximal cystometric capacity increased, while first sensation and pad test were unchanged. Subjective treatment results assessed by visual analogue scales for incontinence and obstrusive voiding symptoms were highly significant. However no biofeedback parameter was improved and no difference could be demonstrated between the two treatment groups. In conclusion the used biofeedback technique is insufficient and the 60 min. standardized pad weighing test is inadequate in this type of patients.

Ciprofloxacin as prophylaxis for urinary tract infection: prospective, randomized, cross-over, placebo controlled study in patients with spinal cord lesion.

To evaluate the efficacy of low-dose long-term treatment with ciprofloxacin in the prevention of recurrent urinary tract infections in patients with spinal cord lesions and neurogenic bladder dysfunction, a prospective, randomized, cross-over, placebo-controlled study was performed. The study period was 12 months long, including 6 months of treatment with 100 mg. ciprofloxacin at night and 6 months of placebo treatment. The study was completed by 18 men and 3 women, median age 38 years (range 19 to 73 years). Within the last 12 months before inclusion into the study, the patients had between 3 and 14 urinary tract infections (mean 5.8) treated with antimicrobial agents. The number of urinary tract infections treated with antimicrobial agents during 6 months of ciprofloxacin prophylaxis was 5 and during the 6 months of placebo treatment it was 59 (p < 0.00005) [corrected]. Fecal specimens showed supercolonization with ciprofloxacin resistant bacteria (Acinetobacter calcoaceticus) in 1 instance. No severe side effects were observed. Ciprofloxacin at a dose of 100 mg. at night was efficacious in preventing urinary tract infections during 6 months in patients with spinal cord lesions and neurogenic bladder dysfunction. After the controlled study 10 of the 21 patients used ciprofloxacin as prophylaxis for up to 39 months with a marked reduction in the pre-study infection frequency. In 1 patient ciprofloxacin resistant Escherichia coli was subsequently found in the feces.

Treatment of lower urinary tract dysfunction in patients with multiple sclerosis. Committee of the European Study Group of SUDIMS (Sexual and Urological Disorders in Multiple Sclerosis)

Bladder symptoms in patients with multiple sclerosis (MS) are common and usually arise as a result of spinal lesions which interrupt the neural pathways connecting the pontine micturition centre to the sacral spinal cord. Thus these symptoms are particularly likely to occur in those with lower limb neurological deficits. Fortunately bladder dysfunction in MS is rarely associated with serious upper tract disease so that the problem is usually one of symptomatic management. Lower urinary tract symptoms may be both "irritative" or "obstructive" in nature and can be explained in terms of underlying detrusor hyperreflexia and incomplete bladder emptying. Treatment is aimed at minimising both these effects. Oral anticholinergic medication can be effective in reducing detrusor hyperreflexia and intermittent catheterisation is used to reduce abnormally high post micturition residual volumes. With this simple treatment, often used in combination, many less severely affected patients with MS can gain considerable improvement in controlling urinary continence.

Plaques causing hemianopsia or quadrantanopsia in multiple sclerosis identified by MRI and VEP.

Four patients with definite multiple sclerosis (MS) gave evidence of demyelinating plaques that produced a form of visual loss atypical of MS, i.e. homonymous quadrantanopsia (women, 22 and 30 years), and homonymous hemianopsia (men, 30 and 42 years). Cerebral magnetic resonance imaging (MRI) identified areas with increased signal intensity situated corresponding to the observed visual field defects. The results of visual evoked potentials (VEP) were in accordance with what should be expected from anatomical considerations.

Assessment of demyelination, edema, and gliosis by in vivo determination of T1 and T2 in the brain of patients with acute attack of multiple sclerosis.

This study intended to investigate the possibility of magnetic resonance (MR) to characterize the acute plaque due to multiple sclerosis (MS). To obtain information, in vivo measurements of relaxation processes were performed in 10 patients with known acute MS plaques, using a whole-body superconductive MR-scanner, operating at 1.5 T. The measurements were repeated several times, from onset of the disease and during remission by use of six-point partial saturation inversion recovery and 32-echo multiple spin-echo sequences, giving T1 and T2, respectively. We also focused on the issue, whether T1 and T2 relaxation processes in fact were monoexponential. The results of the first T1 and T2 measurements of the acute plaques were not clearly different from T1 and T2 of presumably chronic plaques obtained in a group of chronic MS patients previously (H.B.W. Larsson, J. Frederiksen, L. Kjär, O. Hendriksen, and J. Olesen, Magn. Reson. Med. 7, 43 (1988)). In some of the acute plaques a slight initial increase in T1 and T2 was seen, when the measurement was repeated in about 10 days. Thereafter T1 decreased slowly in all but one patient as a function of days. In all cases the T1 relaxation process followed a monoexponential course. The T2 relaxation process was a monoexponential function in the acute plaques, when measured within 20 days from onset of disease. After an average of 78 days, however, the T2 relaxation process clearly became biexponential in all but two patients. Later some of the relaxation curves changed back toward monoexponentiality. Thus, the study shows that it is possible to detect significant changes in MR parameters during the evolution of the disease, and these changes are discussed in relation to knowledge of pathoanatomical events in MS.

Cardiovascular autonomic function in multiple sclerosis.

The autonomic nervous function of the cardiovascular system was investigated by non-invasive methods in 30 multiple sclerosis patients between 20 and 50 years of age. The results were compared to those of 30 healthy controls in the same age group. Minor abnormalities of parasympathetic and sympathetic function occurred. Heart rate variation at deep breathing was reduced and more than half of the patients had abnormal responses during an orthostatic procedure, mainly as an increased rise in heart rate. Decreased rise in blood pressure at sustained handgrip was also demonstrated. The abnormalities correlated poorly with other clinical signs and symptoms in the patients.

A variant form of metachromatic leucodystrophy in a patient suffering from another congenital degenerative neurological disease.

A woman aged 21 with a variant form of metachromatic leucodystrophy (MLD) combined with another form of leucodystrophy is described. The clinical symptoms were retinitis pigmentosa and progressive neurological deficits such as mental retardation, dystonia, pyramidal tract involvement and peripheral neuropathy. The biochemical findings were marked deficiency of arylsulfatase-A and cerebroside-sulfatase in cultured fibroblasts and excretion of sulfatides in the urine. Sulfatide-loading of cultured fibroblasts showed almost normal uptake and degradation of sulfatides. The patient's sister suffers from a clinically similar neurological disease, but normal activity of arylsulfatase-A was found in her leucocytes. A severe oral-facial dystonia in the patient was successfully controlled by l-dopa.

The conductance to outflow of CSF in adults with high-pressure hydrocephalus.

The intraventricular pressure was compared with conductance to outflow of CSF (Cout) in 12 patients with high-pressure hydrocephalus of less than 3 months duration. Cout was measured by a lumbo-ventricular or a ventriculo-ventricular perfusion test. In all patients Cout was very low (median 0.016 ml mm Hg-1 minute-1). Thus high-pressure hydrocephalus may be considered to be the consequence of a greatly increased resistance to resorption of CSF. The level of the measured ICP (mean: ICP 23.5 mm Hg) corresponded to the theoretical level calculated from the measured Cout. B-waves were observed during most of the recording periods and episodes of plateau waves were seen in all patients but one. In this particular group of patients, the unsatisfactory results of ventriculo-atrial shunting emphasize the high risks associated conditions leading to high-pressure hydrocephalus.

The incidence and clinical presentation of neurosyphilis in Greater Copenhagen 1974 through 1978.

The incidence of neurosyphilis in the Greater Copenhagen region was found to be 0.30 per 100,000 inhabitants per year within a 5 year period. This figure is higher than incidence found in other studies from the last decades, but does not represent a statistically significant rise. Using hospital records from relevant departments 23 patients were described. General paresis and meningovascular cases were the most common manifestations. A tendency towards a changing clinical pattern of neurosyphilis was confirmed. Dementia and personality changes were the most frequently observed clinical symptoms. The classical signs of tabes dorsalis were seen in only very few patients. Stroke was a common manifestation. We recommend Standard Serological Tests for Syphilis to be carried out in patients under 60 years of age with cerebrovascular diseases, dementia and in patients where neurosyphilis could be even a remote diagnostic possibility.